Patient and Family Education intermountainhealthcare.org

Managing Chronic Pain

RECLAIMING YOUR LIFE introduction

If you or a loved one has had chronic (ongoing) pain for months or years, you may feel overwhelmed and discouraged. You probably have questions about the future, and about whether things can get better.

There are many ways to manage chronic pain. This booklet can help. It has information, strategies, and tools that will help you take control and manage pain — so you can live a fuller, more enjoyable life.

As you read, keep in mind that this booklet doesn’t replace the instructions you might receive from your healthcare providers. Always follow their directions and go to them with questions and concerns. What’s Inside the many faces of chronic pain...... 4

What is chronic Pain?...... 5 Realities of chronic pain...... 5 Causes of chronic pain...... 6 Common types of chronic pain...... 6 Some effects of chronic pain...... 7 pain management overview...... 8 Assessing your pain...... 9 Making a plan...... 9 Combining pain management approaches...... 10 Working with the people who love you...... 10 how you can care FOR yourself...... 11 Tracking your pain and function...... 11 Getting better sleep...... 12 Balancing activity and rest...... 14 Using exercise to reduce pain...... 16 Balancing your diet...... 17 Managing stress...... 18 Using your mind to minimize pain...... 20 for family and friends Nourishing your spirit...... 22 This booklet is for you, too. Read it to learn more about treatments you may have...... 24 how you can support your Treating the cause...... 24 loved one. Physical therapy...... 24 Psychological treatment...... 26 Also, see the section titled Injections and procedures...... 27 For Family and Friends Complementary and alternative medicine (CAM)...... 27 (page 37), with tips and information just for you. about pain medications...... 29 General safety tips...... 29 Safety with opioid medications...... 30 Addiction — managing the risk...... 32 Common medications used to manage pain...... 35 FOR family AND friends...... 37 pain management tools...... 38 Self-Care Action Plan...... 38 Medication Manager...... 39 Activity Tracking Chart...... 40 Pain Flare-up Plan...... 42 resources...... 43

MANAGING CHRONIC PAIN 3 The many faces of chronic pain All types of people can experience chronic pain, and it can be caused by a range of conditions and problems. The people below represent just a few of the types of chronic pain. Throughout this booklet you’ll see comments based on their experiences. While their experiences may differ from yours, you may find some of their insights helpful in your situation.

Jamie, 22, has had migraine Ernesto, 37, has spinal Leanne, 42, has fibromyalgia. headaches since she was 14, problems that have caused The muscle aches and but they’ve gotten worse — back and leg pain for 2 years. exhaustion feel like an intense and more frequent — since Often it’s difficult to walk, bout of flu — every single day. she started college. work in his yard, or put in a full day at his job as a railroad supervisor.

Ruth, 72, has arthritis that Michelle, 46, has lived with Chris, 28, served his country has gotten worse over time. neck, shoulder, and back for 2 years in Iraq, returning She also has been dealing pain since she was in a car home with injuries that left with nerve pain since she had accident a year ago. Tests show him in near-constant pain. shingles a few years ago. When no spinal damage, but, as she Memories of his experiences the pain is bad, she struggles says, “my pain didn’t see make the pain worse, and the to walk or even get dressed. the x-rays.“ medications have caused their own problems.

4 MANAGING CHRONIC PAIN What is Chronic Pain?

To understand chronic pain, it�s helpful to look first at what pain is and how it works. Pain is a signal passed along by nerve cells, cells designed to send messages. Nerve cells throughout your body can send pain signals to your brain by way of the spinal cord. Short-term pain from an injury — like stubbing your toe — is called acute pain. Acute pain is your body�s awareness that you’re wounded or ill. Chronic (ongoing) pain is more complex. Let’s look at some important differences between acute and chronic pain.

acute pain chronic pain Acute pain is a useful signal. With chronic pain, the signal is no It prompts you to do something — longer useful — the pain is “old news.“ get a cast on a broken bone or rest Long after an injury or illness is healed, the and recover after surgery. When the nerves keep sending the alarm. Or, a chronic condition resolves, acute pain stops. illness causes ongoing pain that can’t be resolved.

The brain can sometimes begin to send and receive its own pain signals even if there is no illness or injury, like a “closed loop.“

Altered or damaged nerves can keep sending pain signals, even after an illness or injury heals.

A chronic illness, scar tissue, or a spinal problem may continue despite Acute pain example: After knee treatment, causing ongoing pain. surgery, nerves around the knee send pain signals. As the knee heals, the signals ease and then stop.

Realities of chronic pain • All pain is real. Even though the pain signals are no longer useful, that doesn’t mean the pain is imaginary. • Chronic pain is complex. Ongoing pain can affect the body, mind, and spirit — and your relationships with others — in ways that many other chronic medical conditions do not. And pain itself can be affected by many factors, such as sleep, mood, and stress. • Chronic pain is common. Estimates of the number of Americans who cope with chronic pain range from 50 million to 116 million. Studies show that 5 times more people live with chronic pain than with diabetes (one of the most common medical conditions). Chronic pain can make you feel isolated at times, but you’re certainly not alone.

MANAGING CHRONIC PAIN 5 Causes of chronic pain Chronic pain can develop from an injury, surgery, infection, or dozens of medical conditions. For example: • After an injury or surgery, nerve fibers can change so they no longer function properly.

• Certain areas of the brain can change over time, so the brain creates pain signals on its own.

• An ongoing medical condition such as rheumatoid arthritis can continue to cause pain for some people.

In some cases, what started the pain or why it continues isn’t clear.

Common types of chronic pain the price of pain There are dozens of specific chronic pain conditions, too many to list here. In the United States, we spend It may be more helpful to think about a few general categories: over $100 billion every year to relieve pain. And if you add • Bone or joint pain is associated with problems in your spine or joints. in the cost from work time The pain can be felt as a sharp sensation or as a dull, constant ache. lost due to pain, the total bill • Nerve pain comes to $560 to $635 billion is caused by damage to the nerves themselves. Symptoms every year. include shooting or burning pain, tingling, or numbness. • Visceral pain is caused by pressure or inflammation (swelling). This pain can feel like a deep ache. The pain often feels as if it’s coming from your internal organs, in your abdomen for example.

• Muscle pain can be caused by muscle tension from a spine or joint problem or by conditions such as fibromyalgia. Muscles can feel sore, achy, or stiff.

• Headache symptoms differ depending on the type of headache. For example, cluster headaches can cause pain that feels burning or piercing. Migraines can cause nausea, vomiting, abdominal pain, sensitivity to light or sound — all in addition to head pain.

With any type of pain, the intensity can vary from person to person and over time. The pain can come and go, it can be relatively constant, and there can also be times of more intense pain, sometimes called pain flare-ups. (See page 42 for a plan to help you deal with pain flare-ups.)

6 MANAGING CHRONIC PAIN Some effects of chronic pain Chronic pain can impact many areas of your life — your sleep, mood, relationships, work, daily routines, and even your sense of self. While each person experiences chronic pain differently, for most people it stirs up difficult emotions. Chronic pain can make you feel:

• Angry. “I kept thinking, ‘What did I do to deserve this?’ I was mad at everyone — my family, myself, even God.” — Michelle

• Tired. “My headaches are exhausting. The pain drains you physically and emotionally. It’s hard to have a normal life.” — Jamie

• Depressed. “Dealing with my back all the time took the joy out of When I got home from everything. It got so I just felt like going back to bed.”— Ernesto Iraq, first I tried to ignore my pain.“ When that didn’t work, • Consumed — and confused. “After a while, it felt like the pain took over I battled it like an enemy — my days. Trying to find out the cause almost drove me crazy.”— Leanne not settling for anything less than NO pain. I was in a fog • Isolated. “I can’t get to family events as often as I used to. I think my of pills and frustration. I kids figure old age is slowing me down, but it’s really the pain.” — Ruth realized I had to look at • Like a different person. “It’s like there was a ‘Chris before’ and everything differently. Now a ‘Chris after.’ It’s changed me in a million ways.” — Chris I’ve accepted that pain may always be with me — but I Chronic pain can cloud your picture of life. But take heart — the picture can manage it. can change for you. Many people with chronic pain have found their way to a better, more satisfying life, and so can you. — chris”, 28, injuries from a military tour of duty

your questions

What are your most pressing questions about your pain?

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2.

3.

This booklet may help answer them. Also, talk about these questions with your healthcare provider.

MANAGING CHRONIC PAIN 7 Pain Management Overview

Pain management aims to reduce your level of pain and minimize its effect on your life, so you can do more of the things that make life meaningful Reclaiming your life and enjoyable. It has several general aspects: Research continues to reveal • An assessment. Your doctor will gather information on your pain and important information about how chronic pain works, how other conditions that may affect it. to treat it, and how to help • A management plan. You and your doctor will work together to create people manage it. a plan based on your goals (see the next page). It will include medical While it’s not common for pain treatments and other strategies that will be used to help manage your pain. to disappear entirely, it can be • Follow-up. In follow-up appointments, your doctor will check how well reduced so it has less impact on your life. Just as important, these strategies are working and change the management plan as needed. management strategies can • Self-help activities. There’s an important role for you to play, because help you function better effective pain management often involves things you do at home. It’s vital despite a certain level of that you take an active approach to managing your pain. This booklet will pain that may remain. get you started on ways to care for yourself and reduce your pain.

• Time and persistence. Chronic pain management is like a journey that can take many turns as you try different approaches and find out what works best for you. It can mean learning new skills — and discovering strengths you didn’t know you had.

Your primary care doctor

If you have chronic pain, it’s especially important to work well with your primary care doctor. These tips can help:

• Be open and honest about your pain, your emotions, and any barriers that may keep you from following the pain management plan.

• Talk with your primary care doctor about any treatments you’re considering. Chronic pain can leave you feeling like you’re in a “medical maze,“ especially when you get tips from friends, family, or the internet about tests or treatments for your condition. Your doctor can give you solid advice.

• Get the most out of your appointments. Bring key family members. Make a list of your most important questions, and ask them first. This helps you get the advice you want without running out of time.

8 MANAGING CHRONIC PAIN Assessing your pain While doctors can often measure symptoms using blood or lab tests, this isn’t true with pain. The only reliable source of information about your pain is YOU. Your doctor needs to know about:

• Your pain history. How did your pain start? What treatments or self-care measures have you tried? How well did they work?

• The nature of your pain. Is it achy, tingly, sharp? How does it change over time? What situations act as “triggers“ to make your pain worse?

• How pain impacts your life. How does it affect your sleep, your mood, My doctor asked so your work, your activities at home? many questions — how often my“ headaches came, how Making a plan long they lasted, how I knew one was coming, what made Based on your assessment, your doctor will work with you to create a pain them worse. management plan that includes medical treatment and things you can do I wasn’t sure I knew all the on your own. A written plan helps you and your doctor decide what will answers! But I gave it my work best to manage your pain, and it helps you track your results over time. best shot. I also decided to Your primary care doctor can also help coordinate treatment with other start keeping a journal to providers. Based on how well each treatment or strategy is working, the track my headaches and plan can be adjusted. what affected them. As part of the plan, you should set a few goals. These are things you’d like — JAMIE, 22, to be able to do, but can’t do because of your level of pain. Think of two or headache pain” three activities that make your life enjoyable — or responsibilities that are important to you or your family — that you’d like to be able to do again. For some people, it’s playing with the kids or walking the dog. For others, it may be going back to work, cleaning the house, or taking a trip.

your goals

Write down three activities that you’d like to do, but can’t do right now because of pain:

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2.

3.

Keep these goals in mind as you create your management plan with your doctor.

MANAGING CHRONIC PAIN 9 Combining pain management approaches Research has shown that the best pain management combines multiple techniques, taking into account the effect of pain on body, mind, and spirit. The combination that’s best for you will depend on your specific pain condition and needs. Because chronic pain often changes over time, it’s a good idea to evaluate what’s working and what isn’t on a regular schedule.

While it’s hard to predict what will work best for you, effective pain management often includes approaches from all three of these categories:

1. Self-care strategies. These may be the most important, because they’re At first, I just wanted a free, you can do them on your own, and they can make other treatments magic pill, something to make more effective. Examples include balancing rest and activity, exercise, “the pain go away forever. But that didn’t work for me. And and stress reduction. toughing it out didn’t work 2. Medical treatments that focus on the body. These include physical either. When did my pain get therapy, injections, medication, exercise, and stretching. better? When I started dealing with it in more than one way. 3. Treatments that focus on the mind-body connection. These can include I’m not sure there’s really a psychotherapy or training in mind-body strategies such as meditation. “magic pill“ for this, at least there wasn’t for me. Working with the people — ERNESTO, 37”, who love you back and leg pain Chronic pain affects your family and close friends — and your relationships with them can also have an impact on your pain. It can help if family and close friends understand what’s causing your pain and what you’re doing to strength in manage it. While you probably don’t want to broadcast your pain condition numbers to the world, it’s important to let the people closest to you know how they You might find it helpful can be involved in your pain management. Sometimes that means giving to join a support group for you extra help. Sometimes that means pulling back a bit, allowing you to people with chronic pain. In a take care of things more often. group, people gain knowledge and strength from each other. You may want to choose a few specific people you can count on — ask them to read this booklet and take a specific role in supporting you. For example, Some of the organizations listed on page 43 have they can be an exercise partner, attend doctor visits with you, or give you information on support emotional support when you have a pain flare-up. groups. Or, ask your doctor if there’s a group in your area.

10 MANAGING CHRONIC PAIN How You Can Care for Yourself

Self care can be more important than medication or pain treatment, because it helps you take control. There are many self-care strategies to reduce pain and make it more manageable, and what works best is different for each person. This section can get you started with strategies that have been helpful for others. To get the most benefit from this information, follow these suggestions:

• Try at least two or three strategies. You’ll never know what might work for you until you try.

• Give each strategy a fair shot. It may not make much difference the first time you try it, but may help a lot the third or fourth time.

Tracking your pain and function Tracking showed me Pain can be affected by many things — stress, certain activities, relationship what works best for my pain. issues, sitting for a long time, even the weather. And it’s different for every “Going for a walk helps more person. Your doctor records a pain snapshot at each appointment, but only than I thought it would, and you can track it day by day to discover its patterns. a hot shower also makes a difference. I knew overdoing Tracking your pain along with your activity, sleep, and other factors can help it was a problem, but tracking you identify your pain triggers — things that spark increased pain. Once helped me see better where you know what they are, you can avoid them, change them, or plan ahead those limits are. I CAN’T help for them if they’re unavoidable. You may know some of your triggers already, my sister pack boxes all day. but tracking may help you identify more and will give you a better picture But I CAN make food for her of how they work. Tracking might also give you insight into which self-care housewarming — and enjoy the party. activities are the best pain tamers. On page 40, you’ll find an activity tracker that helps you make a detailed — mi”chelle , 46, record of pain patterns, your goals and activities, and what helped with pain neck, shoulder, and back pain throughout the day.

your patterns

What do you suspect might be your pain triggers?

The Activity Tracker on page 40 might help you to confirm these — or identify others.

MANAGING CHRONIC PAIN 11 Getting better sleep You probably know through experience that pain can make it hard to sleep. The frustrating flip side is that lack of sleep can worsen pain. This is why getting good sleep is doubly important for you. If pain has robbed you of sleep, try these ideas below.

• Make your bedroom a place that helps you sleep. Use your bedroom only for sleep and intimacy. Make sure it’s quiet and dark by putting telephones and the TV in another room. Make sure your bed and pillow are comfortable, and the room is a comfortable temperature.

• Stick to a schedule. Try to go to bed and wake up at the same time For a long time, I every day. Don’t sleep in, and try not to nap during the day. struggled to get to sleep. Starting“ the day exhausted • Create a bedtime routine. Calming activities such as taking a bath would make me ache even or reading can ready your mind for sleep. more. But now I have a routine that’s helping. I listen to a • Avoid caffeine, nicotine, or alcohol within six hours of going to bed. If meditation CD right before you don’t feel you’re able to do this, talk with your doctor for suggestions. I go to bed, and I use a rice pillow that I heat up in the • Try some calming strategies. Here are some ideas: microwave. The music and –– Relaxation, deep breathing, or meditation can move your mind away warmth work pretty well to from pain and towards sleep. See pages 19 to 21 for some exercises to try. get my mind and body ready for sleep. –– Warmth from a hot water bottle or rice pillow can ease tension and distract you from pain. — LEANNE” , –– Quiet music or a guided imagery CD can help your mind slow down. fibromyalgia

your SLEEP

If you’re not sleeping well, which of the strategies described on these pages would you like to try? What might help you the most?

12 MANAGING CHRONIC PAIN • If you can’t sleep, don’t toss and turn. If you don’t fall asleep in a half hour or so, get up for a bit. Do something boring in another room, with the light kept fairly dim. When you are tired, go back to bed. This helps your mind connect your bed with sleeping.

• Talk to your doctor. Your doctor can help by: –– Prescribing medication to help you sleep. Options include prescription sleep aids or certain antidepressants taken at low doses. (Note: if you take opioid pain medication, don’t take extra doses to sleep, and avoid anti-anxiety medication as well.) –– Evaluating your sleep. Your doctor may refer you for sleep studies to check for other problems — besides pain — that might be keeping you from good sleep. For example, your doctor might want to check for sleep apnea. See the panel below for more information.

Check your sleep apnea risk Sleep apnea is a condition that can keep you from getting the rest you need — and it can be dangerous to your health. The STOP-BANG questions are an easy way to see whether you’re at risk. Do any of these apply to you?

 S nore loudly?  Tired or sleepy during the day?  O bserved not breathing? Check the box if anyone has seen you stop breathing while asleep.  Pressure? Check the box if you have high blood pressure or take medication for it.

 B ody mass index (BMI) over 35? (Ask your doctor what your BMI is.)

 A ge older than 50?  N eck size more than 15 ¾ inches around?  Gender = male?

If you checked 3 or more boxes, talk to your doctor. Your doctor can order tests and help you get treatment.

MANAGING CHRONIC PAIN 13 Balancing activity and rest Chronic pain can affect your relationship to activity and rest, and this can change your life in a big way.

If you’re like many people, daily pain has made you much less active than you were before. You probably have good days when you can do things you enjoy, and bad days when you can do very little. But as time goes on, you may fear that you’re having fewer good days and more bad days. You also might avoid activity for fear you’ll damage something or make the pain worse. If this happens, pain can push you to the sidelines of life. Not only does this cheat you out of experiences that make life worthwhile, it can actually make your pain worsen over time.

On the other hand, some people are determined to ignore their pain at all cost. If you’re like this, you tend to push past your limits, and may even use extra pain medication to get through activities. This approach has a cost — exhaustion, frustration, and increased pain down the road.

About six months ago, Whether you live at one extreme or the other — or visit both at times — I realized pain had turned me the answer is finding the right balance of activity and rest. Finding a “into a couch potato. I’d grit balance may take time, discipline, and patience with yourself, but the my teeth and make it through results are worth it. work, but at home I just watched TV. On weekends I If pain has you on the sidelines didn’t spend time with the kids, help Gloria, or do anything. If pain has made you inactive and your life feels restricted, try these tips:

I decided that had to change. • Start gradually and stretch yourself. A technique called pacing may help. At first I just walked to the Here’s how it works: corner and back. But I went a –– Choose one or two activities you’d like to be able to do — or do for a little further every day, and it longer period — for example walking, sitting at a desk, or housework. got easier. Now I’m cheering the kids at soccer again, and –– Decide how long you can comfortably do the activity now. For example, Gloria and I go for walks you might be able to walk for 10 minutes. together. And we got back to Saturday night dates — I’d –– Divide that time in half to get a starting level. If you can walk for 10 almost forgotten how much minutes, your starting level is 5 minutes. Do this on your good AND fun we can have together bad days. when we go out. –– Each week, add a little more time. For example, the next week walk for 8 minutes daily — on both good and bad days. Gradually, you’ll work — ERNESTO, ” up to more activity than you could do before. chronic back pain

14 MANAGING CHRONIC PAIN • Ask your doctor about activities you can do. You may be surprised. Some activities you’re nervous about may be just fine for you.

• Find new ways to be active. If an activity you used to enjoy is no longer possible, find an alternative. If jogging is out of the picture, you can enjoy the outdoors on a slow walk. An aerobics class may no longer work for you, but you can try gentle movements in a swimming pool.

• Give yourself rewards. Focus on activities that enhance your life — and find healthy ways to reward yourself afterward.

If you tend to push yourself too hard If you often ignore pain and push on through it — and pay the price later — I used to say yes to every try these suggestions to help you find a better balance: request to help in my daughter’s • Narrow your focus. What’s most valuable to you? Spend your energy there. “school, and now I don’t. I choose just a few events that are most If you assess your energy realistically, you can spend it wisely. important to my daughter. • Remember that you have the right to say no — without feeling guilty. Sometimes it’s hard to say If pleasing others is important to you, this may be hard at first. But saying no, but I’ve accepted I’m not no, when needed, can preserve your energy for your true priorities. You Superwoman. Remembering that also have the right to ask for help or complete tasks imperfectly. helps me keep stress and pain under control. • Remind yourself to rest. It can help to schedule periods of leisure or downtime in your day, and treat them as appointments. — michelle, neck ”and shoulder pain

your energy balance

With pain, are you more likely to push yourself too hard, or “drop out“ and avoid activity?

What are some things that make it harder for you to have a good balance of activity and rest?

What are some things you can change to get a better balance?

MANAGING CHRONIC PAIN 15 Using exercise to reduce pain You probably already know how important exercise is to your general health. But you may not be aware of all the ways that exercise can help you manage pain. Chronic pain can make you feel you need to avoid activity, but in most cases the opposite is true. In fact, exercise is one of the best things you can do to reduce your pain over time.

The benefits of exercise Exercise is helpful in these ways:

• It increases the “feel good“ chemicals in your brain. Brain chemicals such as dopamine, serotonin, and endorphins improve your mood and give you better energy. Exercise is proven to boost them. This benefit is even more important with chronic pain, which tends to deplete these chemicals.

• It helps you build strength and flexibility. Stronger muscles and more flexible joints support your body better. And because they are less likely to strain or tense up, they’re less likely to cause you pain.

• It helps you maintain a healthy weight. Losing extra pounds can decrease the stress on your bones and joints, which can reduce your pain.

• It helps your circulation. It’s common for people to take shallow breaths all day. Exercise gets you breathing deeply again, which improves the flow of oxygen, with its healing power, to all parts of your body.

• It increases your overall health. A healthier body functions better overall.

your EXERCISE

What forms of exercise have you tried, and how have they helped with pain? Ask your spouse, friend, or family member to join you in activity — the dog counts, too!

Having company can make exercise a lot more enjoyable.

16 MANAGING CHRONIC PAIN A plan to get started First, talk to your doctor about good exercises for your situation. Try to include aerobic activity (exercise that gets you breathing harder), stretching, and strength building. Good choices for people with chronic pain include walking, pool aerobics, swimming, stretching in a pool or hot tub, yoga, and tai chi. (A physical therapist can help by creating an exercise plan just for you — see page 24.)

Start by setting a modest goal — an amount of time and intensity that you can do regularly on both good and bad days. Every few weeks, increase the time or intensity a little bit. Balancing your diet While research has not proven a definite link between food and pain, some experts feel there is a connection. A few studies have shown that certain foods may make inflammation worse or “spark” pain, so it’s possible that reducing these foods may reduce pain. Some people with chronic pain report that making changes in their diet has helped to ease their pain.

One thing we know for sure — eating a healthy diet is always a good idea. It can help you maintain a healthy weight, for one thing, and carrying extra weight can make pain worse. You may want to try some changes in your diet to see if they help your pain. A good plan is to make just one or two changes at a time. Give each change a few weeks to see if it makes a difference. Try these tips:

• Cut down on — or cut out — foods that may cause inflammation: –– Sugar, including sugary soft drinks –– Refined carbohydrates, such as white bread and noodles –– Junk food, including fast food and most vending machine products –– Deep-fried food –– Food additives, such as MSG (monosodium glutamate) added to restaurant food

• Eat more of these: –– Fresh fruits and vegetables –– Whole grains –– Fish, which can give you omega-3 fatty acids that may help reduce pain

MANAGING CHRONIC PAIN 17 Managing stress Stress plays a key role in how we perceive and experience pain. For example, think about stubbing your toe in these two situations: • Looking for your lost keys, after being late for work 3 days in a row • Getting ready to sit down and watch a movie or game with a friend

In which situation would your toe hurt more? Most people say the frustration of the first situation would intensify the pain of a stubbed toe. Stress makes chronic pain much worse, and an important part of managing chronic pain is managing your stress level.

Managing external stress I used to get a migraine Stress often comes from external sources, such as family demands, job every time I had final exams. situations, or financial pressures. While some sources of stress can’t be “Staying up late studying the removed, you can usually do a lot to reduce your external stress. Page 15 week before, and then the stress of the exam, landed me has techniques for people who push themselves too hard, and they’re helpful in bed the day after. for reducing the stress in your life. Here are some steps to help you think about reducing your external stresses: Now I take more time to study throughout the term, so I 1. Examine your daily routine. Does it include time for rest and leisure don’t push myself so hard at activities? Is it packed with responsibilities and scheduled activities? the end. I also say no to extra 2. Think about your values and priorities. It can help to write in a journal shifts at work so I don’t have about what’s most important to you — and what nurtures your life. to stay up late to study. Last term, I got through finals week Give time and energy to activities that support these values. You may without a migraine. want to schedule them when your energy level is best. 3. Schedule times for exercise, leisure, and taking care of yourself. These — jamie, ” give you the energy and strength for your priorities. chronic headaches 4. Learn to say no to what isn’t important. You have the right to say no, without feeling guilty.

your stress

What situations, obligations, or people cause you the most stress?

How can you reduce their impact on your life?

18 MANAGING CHRONIC PAIN Managing internal stress Factors such as worry or frustration can cause significant stress, but you can take action to reduce these internal factors. While physical exercise can lower stress by boosting “feel-good” chemicals (see page 16), relaxation exercises calm your body and mind. Relaxation exercises help you turn down stress and reduce your body’s response to it. To give one of these exercises a good trial, do it a few times a day for at least several days. It can take some practice to “get the hang of it” and begin to feel the benefits.

• Deep, calm breathing. Breathing exercises are easy to learn, help you relax, and reduce tension. –– Sit or lie in a comfortable position. Place one hand on your belly and one on your chest. Make your belly move with each breath, not your chest. –– Slowly inhale through your nose, silently counting to four. Imagine breathing in a warm, healing light. –– Slowly exhale through your mouth, counting to eight. Imagine breathing out worries and stress.

Repeat these deep, slow breaths at least six times, or for as much time as you’d like to spend.

• Progressive relaxation. This exercise calms tense muscles and can be helpful if you’re having trouble getting to sleep. In progressive relaxation, you contract and then fully relax each part of your body.

–– Sit or lie in a comfortable position. You might want to remove shoes or other restrictive clothing.

–– Focus on one part of your body — your right foot, for example. As you inhale, tightly squeeze the muscles in that part of the body for a few seconds.

–– Exhale and quickly let go of the tension. Let all the stress flow out of that body part with your breath. Focus on feeling the muscles become limp and loose.

–– Enjoy the relaxation for about 15 seconds, and then move to the next body part, until you’ve contracted and relaxed every part of your body.

MANAGING CHRONIC PAIN 19 Using your mind to minimize pain Studies have shown that stress, worry, or frustration can affect the pain we feel from any physical sensation. These emotions and thoughts can “open the gate” to increased pain. But if a gate can be opened, it can be closed as well.

Based on this idea, the pain gate control theory says that you can use specific mental strategies to “close the gate” and lessen the experience of pain. There are several ways to do this, but two of the most common are regular meditation and the practice of noticing and altering your thought patterns.

Meditation exercises to try Meditation has been used in specialized treatment programs for chronic pain Sitting and focusing on since the 1980s, and research shows that it works. In multiple studies with nothing? I didn’t think that people who have chronic pain, meditation has lowered stress, reduced pain, “would help my pain. But it’s and improved the general quality of life. free and doesn’t take a lot of Meditation can take many forms — three common types are mindfulness time, so I decided to give it a try. meditation, reflective meditation, and guided imagery. It’s a good idea to try each type for a while to see which types work best for you. To try meditation, It felt strange at first. My give yourself some time to get used to it and begin to see its benefits. mind raced and I wanted to stop after a minute or two. • Mindfulness meditation helps you focus on the moment rather than on But I kept at it every day. worries or other thoughts. The simplest way is paying attention to your After a few weeks, it got breath. Here’s how: easier — I could meditate for 10 or 15 minutes each time. –– Find a quiet place, sit in a comfortable And it started making a position, and close your eyes. big difference. –– Focus on your breath going in and When I take time to meditate, out. Feel it entering your lungs and I have more energy, less pain, leaving your body. There’s no need and I just feel better. to alter your breath or count each breath. Just rest with the awareness — MICHELLE, of the air flowing in and out. neck and ” shoulder pain –– Your mind will wander, and this is normal. As thoughts occur, briefly note them and return your attention to your breath.

You might want to start with just a few minutes, and then work up to 10 or 20 minutes at a time. Doing this practice regularly — once or twice a day — will help you get more benefit from it.

20 MANAGING CHRONIC PAIN • Reflective meditation involves focusing on a thought or single image as you sit quietly. For some people this can be a form of prayer. Another way to do this is focusing on your hand as it moves over an area of pain, imagining your hand has a healing balm that removes pain. You can also reflect on a beautiful image. As with mindfulness meditation, your mind will probably wander — when it does, gently return to your chosen thought or image.

• In guided imagery, you use your imagination to place yourself in a setting that is beautiful, comforting, and refreshing — and give yourself a “mini-vacation“ from pain and stress. Guided imagery CDs use music and narration to help you do this (see page 43 for recommended resources). You can also do this on your own. Here’s how: NOTICE YOUR THOUGHTS

–– Choose a favorite place — a favorite room, a garden, the beach, Thoughts that can INCREASE pain: a sunny day at the park — any place you feel good and safe. • “I can’t believe how much –– Close your eyes and go to that place in your mind. Notice all the this hurts — and it will colors, sights, textures, sounds, and smells around you. Sink deeply never get any better.” into relaxation as you experience this peaceful, calming place. • “I can’t get back to a normal life until this pain is gone.” Noticing and changing your thought patterns • “This isn’t fair.“ OR, “It’s all Our thoughts about pain can sometimes become automatic, almost like a ______’s fault.” reflex that we’re not aware of after awhile. The problem is that certain types • “In this shape, I’m not worth of thoughts can increase pain. The good news is that by altering your thought much to anyone.” patterns, you can decrease your pain. • “Why can’t they cure this?” Pay attention to your thoughts any time you notice pain or negative emotions. Thoughts that can If you’re like most people, you may notice negative predictions or judgments DECREASE pain: about yourself, your situation, or your pain. Analyze these thoughts. Is there a more positive view that’s truer to reality? See page 43 for recommended • “I know some good ways to manage my pain. I’ll try...” resources to help with this topic. • “I can do some good things While you can do this type of “mind shifting“ on your own, you can also ask today, despite my pain.” a trusted friend or family member to help you notice your negative thoughts • “Today I’m grateful for...” by pointing them out in a non-judging way. A counselor trained in these strategies can be even more helpful. See page 26 for information on therapies • “My daughter (spouse, brother, friend, etc.) loves that can help you in this area. and values me.”

• “I’m a strong person, and today I’ll...”

MANAGING CHRONIC PAIN 21 Nourishing your spirit Chronic pain can be a daily burden that begins to drain your hope, joy, and enthusiasm. It’s important to look for experiences and people that can give you strength and optimism. How to do this is different for everyone, based on your beliefs and experiences.

• Look to your spiritual foundations. What this means is different for each person, and it may or may not be connected to religion. Spirituality can mean connecting to anything greater than yourself or belonging to a greater whole. For some people this means praying and placing trust in God. For others it means meditating on the vastness and beauty of the universe. It may also mean joining a congregation or group of people with similar beliefs who can give you spiritual and practical support.

Spiritual changes • Foster gratitude. Researchers in the field of Your experience with pain may happiness psychology have found that expressing have changed your spiritual gratitude is a key to building emotional strength. outlook or commitments, or You may find it helpful to keep a “gratitude you may be angry at God. journal,“ a list of four or five things you’re These reactions are normal. thankful for each day. Find someone who will • Use your senses to change your perspective. listen — and help you sort through them. Take a few minutes every day to enjoy the beauty and pleasure around you.

Don’t forget fun! For some people, managing their pain becomes a grim daily chore. Don’t let this happen to you.

Remember to let yourself have fun on a regular basis. What makes you laugh? What hobbies or interests spark your zest for life? What things or people bring you joy? Give yourself these gifts as often as you can. You might want to schedule activities that bring fun into your life and treat them as seriously as any other appointment.

22 MANAGING CHRONIC PAIN Your senses can ease pain

Look for beauty. “ I watch the clouds out my window for a few minutes. When my head’s hurting, it helps.”

— Jamie

Smell a pleasant aroma. “ My girlfriend uses scented candles when she’s had a hard day. I love the smell of pine trees in the canyon.” — Chris

Listen intently. “ I put on music, or I just close my eyes in a quiet room and focus on the silence and the small sounds I hear. After a few minutes I feel refreshed. ” — Ernesto

Treat your taste buds. “ I used to throw back a pint of ice cream on a bad pain day. But now I eat a bowl of strawberries and focus on every bite with my eyes closed. It’s like a 10-minute vacation.” — Leanne

Comfort yourself with touch. “ A warm rice bag makes my hands feel better when they’re stiff, but the gentle touch of one of my grandkids can be even better.” — Ruth

MANAGING CHRONIC PAIN 23 Treatments You May Have

Treating the cause A variety of conditions can cause pain symptoms. Managing these conditions not only improves your overall health, but can also reduce your pain. Here are just a few examples:

• If you have diabetes, controlling your blood sugar can help avoid or delay painful nerve damage.

• If you have rheumatoid arthritis, medications that suppress the immune system can slow the progression of the disease and also ease pain. • If you’re overweight, reaching and maintaining a healthy weight can relieve pressure on your joints, reducing pain.

Some days I could barely • If you smoke, quitting tobacco can reduce your pain. While smoking is walk — and sitting was torture. rarely the primary cause of pain, studies show that it can make pain worse. “Physical therapy made a difference for me. I felt better If your doctor identifies a medical condition as a cause of your pain, you after each appointment, but the have an even stronger reason to manage the condition. Ask your doctor best thing was the set of back what you can do. stretches she showed me. Every morning I try to remember Physical therapy to do them. When I do, I feel a Pain can make muscles tighten or go into spasm, so your body is more lot better and I can get tense. You move less, so you become less fit and flexible. This in turn can more done. increase your pain. Physical therapy helps to break this vicious cycle. Physical therapy can relieve pain, promote healing, and help you move — ernesto” , back and leg pain and function better. Many physical therapists are trained in pain management principles.

Inactivity Pain and inactivity can cause a vicious cycle. Pain

A physical therapist can help you break the cycle. Stiffness

24 MANAGING CHRONIC PAIN A physical therapist will create a treatment plan designed to meet your needs. The plan might include:

• Guided exercises. These include stretches and exercises that help you regain flexibility, strength, and conditioning, so you can do more.

• Help with “body mechanics.“ This involves learning and practicing ways to sit, stand, and walk that ease your pain.

• An exercise plan to use at home. This type of plan is unique to your condition and needs, and aims to reduce your pain by building flexibility and strength in key areas.

To get started, coordinate with your doctor and check your insurance plan. I used to ski and Some insurance companies require a referral from your doctor and may mountain bike a lot. But after place limits on your annual number of visits. “I got back from Iraq, I couldn’t handle how skiing or mountain biking jarred my body. My physical therapist helped me figure out good ways to be active again.

Now I swim a couple times a week. I hit the trails where I used to mountain bike, but I walk instead. And I got a road bike — my girlfriend and I ride around town.

— chris, injuries” from tour of duty in Iraq

More movement can mean less pain

For most patients with chronic pain, exercise is critical for recovery. If you fear that any exercise might do further damage, please don’t worry. The truth is, the right type of exercise can actually reduce pain and help you function better.

A physical therapist can advise you about exercises that are safe and will help you heal. You can also ask your doctor about what exercises will work for you. You’ll probably be surprised at how much you can safely do.

MANAGING CHRONIC PAIN 25 Psychological treatment The daily experience of pain can be discouraging, frustrating, scary, or exhausting. Psychological treatment can help with depression or anxiety, and can also help you learn mental strategies to minimize pain.

Treating depression or anxiety Depression and anxiety are caused by an imbalance of chemicals in the brain. These conditions are common for people with chronic pain. While pain itself can cause some symptoms of depression or anxiety — such as trouble sleeping or difficulty concentrating — your doctor can use specific criteria to check your combination of symptoms and make a diagnosis.

These conditions are treatable, and it’s important to pursue treatment. Not only do these conditions make life a struggle, research shows they can also When my doctor make pain more intense. Treatments include medication, counseling, or both. suggested counseling, I thought“ she was saying the If you’ve begun to think about suicide, contact your doctor right pain was all in my head. away. Depression, combined with pain, can lead a person to think of ending I was frustrated at first — my it all. These thoughts put you and your family at risk. Immediate treatment muscles ache, and I need to is available, and can help you see the value of life clearly again. talk to someone?

But my doctor explained how Counseling to help minimize pain pain and emotions affect each Counseling can often help reduce pain. For example, studies have shown other. Pain is complicated — that psychodynamic therapy — counseling focused on understanding it affects my stress, and stress relationships — can reduce pain levels, in addition to helping people solve can make my pain worse. I relationship problems. decided to give counseling a try. I learned some new ways A counselor trained in pain management can to cope that have helped with also teach you ways to decrease thoughts that my pain. can make pain worse and increase thoughts that can ease pain. One technique to help you — leanne” , do this is cognitive behavioral therapy (CBT), fibromyalgia which can make a difference fairly quickly for some patients. In addition, a counselor can coach you in meditation, guided imagery, and other relaxation techniques. No matter how severe or long-lasting your pain has been, these strategies may help. You have more power over your mind ­­than you realize, and you can use this power to minimize pain.

If you’re interested in counseling, ask your doctor to refer you to a counselor or group class. (See page 20 to learn how to try some of these strategies on your own.)

26 MANAGING CHRONIC PAIN Injections and procedures For some types of pain, procedures might be recommended to help diagnose what’s wrong, to treat pain, or both. Because they involve using a needle or scalpel, these treatments are sometimes called invasive therapies. They include injections, spinal cord stimulation, and implanted drug-delivery systems (“pain pumps”).

• Injections put medication directly into a painful area. For example: –– Trigger point injections put medication into a pain “hot spot,” such as in the shoulder or neck. –– Epidural cortisone injections place numbing medication and cortisone (a steroid) into the space between the bones and nerves. The injections My neighbor suggested can ease inflammation and nerve pain. Nerve blocks are similar, but acupuncture, so I asked they target an individual nerve in the spine or other painful area. my“ doctor about it. He had read some articles about –– Facet blocks that place medication into a joint in your spine. These acupuncture for arthritis, and can be used to relieve pain or diagnose the source of pain. recommended someone he –– Radiofrequency rhizotomy uses a special needle that applies thought was qualified. radiofrequency energy to destroy nerve cells near a joint in your spine. Acupuncture hasn’t been This keeps the nerves from sending pain messages to your brain. the total solution for me, • Spinal cord stimulation requires surgery to implant a small device into but it does reduce pain and your back. The device delivers mild electrical signals to the spinal cord, stiffness for a week or so after which can interrupt the flow of pain signals to your brain. This strategy a treatment. When my knees get really bad in the winter, is not used unless most other treatments have failed. the acupuncture helps. • Implanted “pain pumps“ deliver a constant level of pain medication — RUTH, internally. Like spinal cord stimulation, this strategy isn’t tried unless arthritis ” pain is severe and constant, and many other treatments have failed. A small pump is surgically placed under the skin and is used to deliver pain medication directly to the area surrounding the spinal cord.

If your doctor recommends an injection or procedure, check with your health insurance to see if it’s covered and if there are any requirements for coverage.

check the cam Complementary and alternative research medicine (CAM) You can find current The phrase complementary and alternative medicine (CAM) is used for research on CAM therapies treatments usually offered by providers that are not in the traditional realm at the National Center for of medicine. While people often report that CAM therapies help with Complementary and Alternative chronic pain, these therapies have limited scientific evidence to support Medicine, presented by the National Institutes of Health, at them. However, the scientific research on CAM is growing (see the www.nccam.nih.gov note at right).

MANAGING CHRONIC PAIN 27 Advice on using CAM CAM therapies work best if they’re integrated with your doctor’s care. In other words, don’t go it alone. Follow these general tips:

• Be wary of miracle cures, especially if they’re risky or expensive. On bad pain days, you might feel like you’d try anything. But promised relief isn’t worth risking your safety — or draining your bank account.

• Keep your doctor informed. Your doctor may have advice on the risks and benefits, and may be able to refer you to a trustworthy practitioner. Your doctor can also help you avoid any dangerous interactions between complementary therapy and your other treatment. For example, even seemingly harmless herbal remedies can interact with other medications.

• Check your insurance plan first. Complementary medicine is usually not covered, but some insurance plans may give you a discount.

CAM therapies Below are descriptions and tips about the most common CAM therapies.

Therapy Keep in mind

Chiropractic: Chiropractic treatment generally If you have spinal injuries, involve your doctor in your involves adjusting the joints of the spine, with the goal decision to pursue this treatment. An overly aggressive of releasing energy and reducing pain. manipulation can make you sore afterwards. High velocity neck manipulation is dangerous. This treatment is most effective if it’s combined with exercise.

Massage therapy: Massage focuses on reducing Check credentials to make sure the therapist is licensed. stress, easing muscle tension, and increasing blood If you have cancer, heart problems, infections, skin flow, with the goal of reducing pain. problems, or blood clots, ask your doctor if massage is safe for you.

Acupuncture and acupressure: Using needles As with other complementary therapies, make sure or fingertip pressure, these therapies aim to balance acupuncture or acupressure are integrated into your regular energy in the body and help it flow smoothly. medical care.

Mind-body therapies: These therapies help you Your doctor may be able to give you a referral to a use your mind to reduce pain. They include hypnosis, psychologist with special training or to group sessions. biofeedback, guided imagery, and meditation. See pages 20 and 21 for some meditation exercises you can Providers might use these strategies with you, or try on your own and see the resources on page 43 for CDs teach you how to use them yourself. and books that can help.

Herbs, supplements, and homeopathy: Herbal These could interact with medications you already take, remedies, vitamin supplements, or homeopathic possibly in a dangerous way. Tell your doctor about herbs, treatments, are used to treat symptoms or boost the supplements, or other remedies before taking them. body’s immune system.

28 MANAGING CHRONIC PAIN About Pain Medications

Medications can ease pain, help you sleep, or treat other symptoms. (See pages 35 and 36 for a table listing common medications used to treat pain.) It’s important to remember that medication rarely removes pain completely. A realistic goal is to reduce pain by 30% to 50%, so you can use other strategies to manage it. While medications are part of pain management for many people, they shouldn’t be the only part of your plan.

Pain medications can have side effects and risks, which can increase when they’re taken for a long time. Opioid pain medication can be particularly tricky (see pages 30 to 34). Follow the tips in this section to take pain medications more safely.

General safety tips I used to take a lot of • Tell your doctor about ALL medications you take. Include everything — Tylenol for my back pain. On other prescriptions, over-the-counter drugs, herbs, and vitamins. “bad days, I popped them like candy. I figured it was no big • Talk with your doctor — and ask lots of questions — before starting deal — just Tylenol from the any new medication. Ask why it’s recommended and what to expect. grocery store. When I told Ask about side effects and how you should take the medication. my doctor, he said I could be damaging my liver by taking • At the pharmacy, make sure you understand the directions. Read the so much Tylenol. Now I tell directions on the bottle and see if they make sense to you. If they don’t, my doctor about anything ask the pharmacist to explain. I’m thinking of using • Follow the directions exactly. Do not change your dose, or how often for pain. you take the medication, without telling your doctor in advance. — ERNESTO, • Keep track of your medications. Use the chronic” back pain medication chart on page 39 to record your medications and how to take them. Keep track of how much you have, so you don’t run out suddenly.

• Talk to your doctor before making your medications ANY changes. Before taking If you have questions about your medications, jot them below: anything new (including over-the- counter pills or herbs), ask your doctor. It might react with your medication in a bad way.

• Avoid alcohol or recreational drugs Bring them to your next appointment and ask your doctor. while taking pain medication. These can be dangerous when combined with any type of pain medication.

MANAGING CHRONIC PAIN 29 Safety with opioid medications Opioid medications (sometimes just called “opioids” or “pain pills”) are strong medications designed to reduce pain so you can function better. But opioids also pose unique risks because of the way they affect the brain.

If your doctor prescribes opioid medication, you’ll need to take extra caution. Follow all the general safety tips on page 29, plus the extra safety tips below. Your doctor will work with you to help reduce side effects and manage the risks of opioid therapy.

Guarding against dangerous side effects Opioids can cause a variety of side effects, listed in the table on page 36. Your doctor will work to help you manage these side effects. Some side effects can be dangerous, and you’ll need to take steps to lessen the danger.

• Opioids can decrease your breathing, especially while you sleep. Also called respiratory depression, this side effect is a lower “drive“ to breathe that can rob you of oxygen and even cause death. Take these safety steps:

–– Talk to your doctor about factors that can increase the risk. Sleep apnea is a common condition that leads you to stop breathing many times during the night. See page 13 for a list of sleep apnea risk factors, and talk to your doctor about screening. Also, if you are overweight or have lung disease, talk to your doctor.

–– Don’t drink alcohol. Also, avoid medications that can increase the risk. For details, see the medication list in the “Side effects, warnings” column of the table on page 36. It’s a good idea to avoid any medications that make you sleepy.

–– Tell those you live with that you’re starting a medication that can affect your breathing. Ask them to watch for slower breathing and have them check to make sure you can wake up. If your breathing is slow or you can’t wake up, they should call 911. Healthcare providers can inject a support for safety medication to reverse the problem.

See page 43 for groups that • Opioids can change your awareness or judgment. They can make provide additional information you feel sleepy, tired, or dizzy. They can also slow your reactions and and support for taking opioids affect your ability to make decisions. As you can imagine, any of these safely. For example, the side effects can be dangerous if you’re behind the wheel. For your safety, American Pain Foundation’s do not drive a car or operate machinery while taking opioid medication, PainSAFE program provides at least until you know how it affects you. If you drive unsafely or cause tools for both patients a car accident while taking opioids, you can get a DUI (driving under the and families. influence) ticket, even if you have a prescription.

30 MANAGING CHRONIC PAIN Protecting others Opioid medication can be very dangerous if taken by someone else. If you’re taking opioid medication, here are some important ways you can keep everyone safer:

• Don’t share. Even if a friend or relative has had a prescription for pain medication before, even if they are in severe pain, it’s not worth the risk. Sharing pain medication is illegal and dangerous.

• Lock it up. Opioids can tempt others. One in five teens report using someone else’s prescription drugs, often getting them from the medicine cabinet at home or a friend’s house. Experimenting with opioids can lead teens to other I used to keep my pain drug abuse — studies have shown that pills in the bathroom. But after opioids are a common “gateway drug” to “my book group met at my teen heroin use. Use a cabinet or drawer house, I noticed half my pills with a lock on it, and keep track of were missing from the bottle. how many pills you have. That got me thinking my pain • Store it in its original bottle. This prevents confusion, and is doubly pills could be dangerous for important if you travel. Airline security requires you to have medication my teenage grandkids and for in the original bottle. anyone else coming over.

• Get rid of it when you’re finished. For all the reasons listed above, Now I keep my pain pills in a don’t hold on to opioid medication when you’re no longer taking it. locked desk drawer. It’s safer The FDA recommends two ways of getting rid of opioid medication: for everyone. –– Drop it off at a collection site. To see a list of sites in Utah, go to: — ruth, 72 www.medicationdisposal.utah.gov/permanentsites.htm arthritis” pain –– Flush it down the sink or toilet. This isn’t the method the FDA recommends for other medications. But because of the danger with opioids, they suggest flushing as a way to rid of them as fast as possible.

Preventing withdrawal If opioid medication is stopped suddenly, you can have uncomfortable withdrawal symptoms such as cramps, diarrhea, fast heartbeat, sweating, and body aches. Here’s how to help prevent them:

• While you’re taking medication, keep track of what you have so you don’t run out without warning and have to stop suddenly. (Call for refills during regular office hours, so your doctor can write a prescription if needed. Many “covering” doctors will not write opioid refill prescriptions.)

• When it’s time to stop taking opioid medication, your doctor will help you taper off the dosage gradually.

MANAGING CHRONIC PAIN 31 Addiction — managing the risk Opioid therapy can pose a risk of addiction. Although most people don’t become addicted, the risk is significant enough that you should know what addiction is and how your doctor will help to manage the risk.

Opioid addiction can have serious consequences, including death from unintentional overdose. In 2010, unintentional overdoses killed more people in Utah than car accidents. Addiction can also ruin careers and relationships.

What is addiction? It’s important to understand what addiction is and what it isn’t. There are actually three terms to know — dependence, tolerance, and addiction.

• Dependence simply means your body has adapted to medication, so you may have withdrawal symptoms if you stop suddenly. These can include cramps, diarrhea, achiness, sweating, or restlessness. To help prevent these, your doctor will have you “taper off“ when it’s time to stop.

• Tolerance means that over time the medication doesn’t work as well, because your body has adapted to the medication quite a bit. If you feel your body is building a tolerance, tell your doctor — don’t just take a higher dose on your own. Your doctor can change your prescription or add another strategy to your plan.

• Addiction is a disease that affects how the brain works — especially in the way that it processes rewards, motivation, and memories. It causes symptoms that affect a person’s body, mind, and spirit. Addiction can cause a loss of control — it feels impossible to stop using a substance, even when it causes bad problems. Addiction can cause strong cravings, affect emotional responses, and keep a person from recognizing problems with behaviors or relationships. It’s important to know that addiction is not a moral failing, even if it causes behaviors that a person regrets.

32 MANAGING CHRONIC PAIN What’s the risk of developing addiction? The risk of opioid addiction is low for most people, but it may be higher for people with risk factors. Research shows that addiction risk often runs in families, so your family history is important. Studies also show various other factors can increase the risk — including tobacco use, certain mental health conditions, trauma or abuse earlier in your life, and heavy alcohol use.

Even if you have some of these risk factors, you may be able to take opioid medication without developing problems. But it’s important to start with open eyes, not ignoring the risks. Your doctor can assess your risk and take steps to reduce your chance of developing an addiction.

Managing the risk You and your doctor will work on a plan to help maximize what medication can do FOR you and minimize what it can do TO you. Steps may include: I’ve never had issues • A risk assessment. Your doctor may use a form to help identify risk factors, with addiction, but my doctor and will probably ask about them as well. Answer honestly — your safety “said he screens everyone is at stake. before they start taking pain • An agreement. If you are prescribed opioids for more than a week or two, pills. As it turns out, I have a your doctor may have you sign an agreement that spells out safety steps couple of risk factors in my you and your doctor will take. The agreement may be detailed, so ask family history. questions about anything unclear so you know what you’re signing. At first I was afraid my doctor • Follow-up visits to see how things are going and re-assess your risk. saw me as an addict — but These can be once a week, once a month, or every few months. that’s not what’s going on. He just wants to keep me safe. • Pill checks or urine tests. Your doctor may ask you to bring your I’m glad about that. prescription bottles to some appointments. You may also have urine tests to check for medication from time to time. — michelle, ” These steps do NOT mean your doctor assumes you’ll run into trouble. Neck and shoulder pain Rather, your doctor wants to help you avoid the added problem of addiction on top of chronic pain.

MANAGING CHRONIC PAIN 33 Watching for warning signs You can watch for signs that your medication may be becoming a problem. Talk to your doctor if:

• Medication doesn’t help as much. It may stop decreasing your pain, even if the dose keeps increasing or you take it more often.

• Medication makes it harder to think, feel, or function. You might be “foggy“ or struggle to concentrate. You might begin to rely on its emotional effects. Or, it might decrease your activity, so you do much less.

• Medication affects your work or relationships. If you can’t work because of the medication, or if it causes relationship problems or family concerns, Pain meds ended up this is a significant warning sign. doing me more harm than good.“ Almost without realizing it, I started using them for If addiction develops emotional pain as much as If you begin to worry about how your pain medication is affecting you, tell anything else. But soon they your doctor. Remember, addiction is not a moral failing — it’s a disease that didn’t work very well. I kept can be treated. taking more, but it didn’t help. • How is addiction diagnosed? An evaluation involves asking questions and Everything ended up in kind of comparing your answers with specific criteria. It’s important to be honest a blur, and I wasn’t involved in in your answers. Sometimes it can help to get the viewpoint of someone my life anymore. I didn’t want who knows you well — you might want to bring a friend or family to think of myself as addicted, member along. but my parents and girlfriend were worried and asked me • How is it treated? First, know that it’s possible to treat addiction AND to get help. And I decided I pain at the same time. There are many treatment options, including wanted to get back to life. group programs, one-on-one programs, and medication. You and your I talked to my doctor, who doctor will work on a treatment plan based on your situation and what referred me to a program that may work best for you. You should know that special laws protect your helped me get off the opioids privacy related to addiction treatment. By law, an addiction treatment and manage pain in other program cannot tell anyone that you are in treatment without your ways. A lot of things are better written consent. now, including my pain.

— CHRIS, multiple injuries” from tour in Iraq

34 MANAGING CHRONIC PAIN Common medications used to manage pain

Medication Side effects, warnings

Acetaminophen: Acetaminophen treats mild to moderate • Do not take more than 4,000 mg per pain. It’s also sometimes included in other prescription day. Can damage the liver if taken at medications to make them work better. higher doses. Examples: Tylenol and many other prescription and • Can cause bleeding problems if taken with over-the-counter (OTC) medications warfarin (Coumadin).

NSAIDs (Nonsteroidal anti-inflammatories): NSAIDs treat • Never use more than is listed on the package mild to moderate pain. They’re also sometimes included in directions without talking with your doctor. other prescription medications to make them work better. For example, do not take more than 4,000 mg of aspirin or more than Examples: aspirin, ibuprofen (Advil), naproxen (Aleve), 3,200 mg of ibuprofen per day. fenoprofen (Nalfon), ketoprofen (Orudis), oxaprozin (Daypro), indomethacin (Indocin), piroxicam (Feldene), • Can cause problems for your stomach and colecoxib (Celebrex), and others; also in many other digestion; another medication might be combination prescription and OTC medications prescribed to protect your stomach. • Can cause bleeding problems if taken with warfarin (Coumadin). • Can increase heart risks; your doctor may check your heart health before prescribing.

Antidepressants: Antidepressants treat pain symptoms, • Talk to your doctor about potential side depression caused by pain, or both. Depending on the effects. Depending on the type of medication, medication, antidepressants can help with nerve pain, these can include sleepiness, dizziness, dry back pain, headache, migraines, or fibromyalgia. mouth, nausea, constipation, weight gain, or blurred vision. Examples: amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil), doxepin (Sinequan), duloxetine (Cymbalta), milnacipran (Savella), venlafaxine (Effexor), bupropion (Wellbutrin), and others. Note: SSRIs such as Prozac, Paxil, and Zoloft are not often used for pain.

Anticonvulsants: While anticonvulsants prevent seizures, • Talk to your doctor about potential they also help nerve pain because they “calm down“ the side effects. Depending on the type of nervous system. Anticonvulsants can help with various nerve medication, these can include sleepiness, pain conditions; the medication chosen by your doctor will dizziness, weight gain, and other depend on the type of nerve pain you have. side effects. Examples: gabapentin (Neurontin), pregabalin (Lyrica), oxcarbazepine (Trileptal), carmabazapine (Tegretol), phenytoin (Dilantin), topiramate (Topamax), and others

Lidocaine skin patches: Lidocaine patches, placed directly • May cause minor skin irritation. on a painful area, can ease arthritis and nerve pain. • Wear the patch for 12 hours, then take Examples: lidocaine (Lidoderm) 12 hours off.

MANAGING CHRONIC PAIN 35 Common medications used to manage pain, continued

Medication Side effects, warnings

Opioids: Opioids reduce pain by changing the • Avoid these medications if you are taking opioids: way your brain processes pain. Short-acting clonazepam (Klonopin), alprazolam (Xanax), lorazepam opioids usually work for 3 to 6 hours. Long- (Ativan), zolpidem (Ambien), antihistamines (such as acting opioids usually work for 12 to 24 hours. Benadryl), anti-nausea medications (such as Phenergan), and muscle relaxants (such as Soma). Short-acting opioid examples: • Can cause decreased breathing (respiratory depression). Codeine (Pyregesic, Tylenol #3 or #4, Vopac); This side effect can be deadly. It is more common in hydrocodone (Lortab, Vicoden, Vicoprofen); patients with obesity, sleep apnea, lung disease or hydromorphone (Dilaudid); meperidine alcohol use. (Demerol); morphine (MSIR); oxycodone IR (Percocet, Percodan, Combunox, Roxicodone); • May also contain acetaminophen or ibuprofen; do not oxymorphone (Opana IR); tramadol (Ultram, take extra acetaminophen or ibuprofen. Ultracet); tapentadol (Nucynta) • Can cause constipation. Drink extra water and take fiber, a laxative, or a stool softener. Long-acting opioid examples: Hydromorphone ER (Exalgo); extended release • Can affect awareness or judgment. Can make you sleepy, tramadol (Ultram ER); methadone; sustained tired, or dizzy, with slower reactions. action morphine (MS Contin, Avinza, Kadian, • Can pose risks in pregnancy, including increased risk of Embeda); sustained action oxycodone birth defects or infants going into withdrawal after birth. (Oxycontin); oxymorphone (Opana ER) • Can cause other body effects: itching, sweating, nausea, vomiting, dry mouth, or difficulty urinating. • Can lower levels of testosterone (a hormone) — this can reduce your energy, sex drive, or bone strength. • Can affect your mood and perception. Can make you feel “low“ (mildly sad) or “high.“ Can alter your taste or vision, or lead you to see or hear things that aren’t there. • Can lead you to develop a tolerance, so the medication doesn’t work as well. If the medication is stopped suddenly, can cause withdrawal symptoms. • Can make you more sensitive to pain over time. • Can pose a risk of addiction or abuse. See pages 30 to 32 for more information.

Opioid skin patches: Medication is absorbed See the side effects and warnings above. through your skin, but doesn’t numb that area. They are also true for opioid patches. Instead, an opioid patch reduces pain by altering • Do not put heat on a patch or cut a patch. the way your brain processes pain. Depending on the type of patch, each patch stays on for • Do not put on two patches at once. 3 to 7 days. See pages 30 to 32 for more information. Examples: fentanyl transdermal system (Duragesic), buprenorphine transdermal system (Butrans)

36 MANAGING CHRONIC PAIN For Family and Friends

If someone you love has chronic pain, you’re affected too. You might be anxious or sad about your loved one’s pain. You might have taken on new responsibilities to support your loved one or meet your family’s needs. Chronic pain can also lead to money problems and other sources of stress.

In the midst of these challenges, you need to take good care of yourself.

• Reach out for support. Don’t let your worries build up inside. Talk to friends, a spiritual advisor, or your healthcare provider.

• Don’t neglect your health. Get a good night’s sleep, eat a healthy diet, find times for exercise and activity, and find ways to manage stress.

• Keep a sense of balance with your loved one. Your loved one’s pain is real, Your loved one’s pain is real, and it’s easy to feel you need to do everything you can to “pick up the slack.” and it’s challenging in many But taking over too many responsibilities isn’t a good idea. It can keep your ways — including relationships. loved one from activity and actually increase your loved one’s pain over time. See the tips below about communication and finding balance.

Relationships and chronic pain

I wanted my husband to know how much I hurt, so he would help more with “housework. But he started tuning out. I know it’s hard to hear someone complain all the time. So now, on bad pain days I just tell him my pain score — and ask him for help with specific tasks. ” — LEANNE Leanne used to talk a lot about her pain. I love her and care deeply, but I couldn’t “fix it and I couldn’t read her mind about what she needed. Now we just use a number. When it’s a 6 or 7, she asks me for more help. ”— RICHARD, Leanne’s husband

I really worried about Michelle when all this started. Her pain was intense, and she“ needed me. So I dropped out of my bowling league, stopped going to church, and just stayed home and tried to support her. But I have to admit, I started burning out.

— ROGER, Michelle’s husband ”

I loved having Roger around, but what I needed more than anything was to know “he was happy. I felt guilty about keeping him from activities, and that made my neck hurt more. I told him I wanted him to do more with his friends. That gives me time to read and garden. ” — MICHELLE

MANAGING CHRONIC PAIN 37 Pain Management Tools

Self-Care Action Plan This workbook describes many self-care strategies to help you manage pain and reclaim your life. Use this page to record those you plan to try. Self-care gives you more control ­— and it can be as effective as medical treatment or even more. Try one or two strategies at a time, and keep using those that work well. Remember, to give a strategy a good chance to work, try it regularly for at least a few weeks.

Pain Management Goal Three things I'd like to be able to do, that I can't do right now because of pain:

So I can do the things above, my goal for pain management is to reduce my pain to ______. (Enter a number from 0 to 10, with 0 being no pain and 10 the worst pain you can imagine. A realistic goal is to reduce pain by 40%, and most people can do the things they'd like to do if they can keep their pain at a level of 3 or 4.)

Body Mind and Spirit Sleep. Strategies I'll use to get better sleep (page 12): Managing stress. My plan to reduce sources of stress (page 18):

Balancing activity and rest. Strategies I'll use to get a better balance — not staying on the sidelines and not Relaxation and meditation. My plan to use relaxation pushing myself too hard (page 14): and/or meditation exercises to ease pain (page 19-20):

Exercise. Types of regular exercise I want to try (page 16): Thought patterns. My plan to notice thoughts that foster pain and replace them with thoughts that reduce it (page 21):

Nurturing spirit. Ways I plan to nurture my spirit, add Nutrition. Dietary changes I want to make (page 17): joy into my life, and have fun (page 22):

Maintaining relationships. Relationships with supportive people can help you in all the areas listed above. Make a plan to connect with family and friends in a way that fits your natural style of asking for and accepting help:

38 MANAGING CHRONIC PAIN Medication Manager Use this page to record your notes on medication for pain and other conditions. Make copies of this page if needed. Remember: Lock up opioid pain medications, and dispose of any leftover medication — see page 31.

Medication How to take When/how often to take

Name: o With food o Breakfast o Lunch o Dinner o Bedtime Dose: o NO food What it looks like: color/shape OR What it’s for: o As needed, NO MORE THAN times per day

Special instructions:

Medication How to take When/how often to take

Name: o With food o Breakfast o Lunch o Dinner o Bedtime Dose: o NO food What it looks like: color/shape OR What it’s for: o As needed, NO MORE THAN times per day

Special instructions:

Medication How to take When/how often to take

Name: o With food o Breakfast o Lunch o Dinner o Bedtime Dose: o NO food What it looks like: color/shape OR What it’s for: o As needed, NO MORE THAN times per day

Special instructions:

Medication How to take When/how often to take

Name: o With food o Breakfast o Lunch o Dinner o Bedtime Dose: o NO food What it looks like: color/shape OR What it’s for: o As needed, NO MORE THAN times per day

Special instructions:

MANAGING CHRONIC PAIN 39

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MANAGING CHRONIC PAIN 41 Pain Flare-up Plan A pain flare-up is a period of much more intense pain. Stress, illness, and a host of other factors can cause a flare-up. A flare-up can send you into a panic if the pain feels out of control. You may even be tempted to head to the emergency room sometimes — but it’s much better to avoid the ER by having a Flare-up Plan in place ahead of time. Below are some basic elements of a Pain Flare-up Survival Plan. Complete the sections of the plan now, so you can return to this page the next time you have a flare-up.

Your Flare-up Plan

Affirm your strength. Write a statement here that will remind you that you have the strength to get through this pain flare-up. (Here are some examples: “I’ve gotten through this before, and I can do it again.“ “I will survive this — it won’t last forever.“ “I’m a strong person, and I can do this.“)

Use your best self-care strategies. What self-care strategies usually work best for your pain? Write them here. When the pain is intense, it can feel as if your normal measures won’t help — but you may be surprised.

Strategy 1:

Strategy 2:

Strategy 3:

Seek support. Ask two people ahead of time to help you get through flare-ups. They may or may not be family members — what’s important is that they’re usually available, know you well, and are good at helping you stay calm in a crisis.

Name: Phone number:

Name: Phone number:

Use your medication plan. If you take regular pain medication, talk to your doctor about a “rescue dose“ to use if pain flares out of control. Make a note of that specific dose here — and stick to the plan.

Medication: Dose:

42 MANAGING CHRONIC PAIN Resources

Use the resources listed here to learn more about chronic pain and how you can effectively manage it.

Books and CDs Websites and Organizations

• A Day Without Pain. Mel Pohl and Mike Donahue. Central • www.intermountainhealthcare.org/chronicpain Recovery Press 2008. Intermountain’s Chronic Pain Online Center includes educational materials and tools. • Dissolving Pain: Simple Brain-Training Exercises for Overcoming Chronic Pain. Les Fehmi and Jim Robbins. • www.painaction.com The Pain Action website provides resources that show Trumpeter 2010. (Book and CD) you how to manage chronic pain, learn what works for you, • Back Sense: A Revolutionary Approach to Halting the accomplish your goals, get the most out of your medical Cycle of Chronic Back Pain. Siegel, Urdang, and Johnson. care, and achieve the quality of life you deserve. Three Rivers Press 2002. • www.theacpa.org • Managing Pain Before It Manages You. Margaret The American Chronic Pain Association offers peer Caudill. Guilford Press 2008. support and education to help people manage pain, including management tools, videos, articles on pain • Mindfulness Meditation for Pain Relief: Guided conditions, and an annually updated Consumer Guide to Practices for Reclaiming Your Body and Your Life. Pain Medications and Treatments. Jon Kabat-Zinn. Sounds True 2009. (Audiobook/CD) • www.painfoundation.org • The Mindfulness Solution to Pain: Step-by-Step The American Pain Foundation (APF) provides an Techniques for Chronic Pain Management. extensive clearinghouse with articles and links on finding Jackie Gardner-Nix. New Harbinger 2009. and evaluating treatment, medication safety, issues faced by veterans, and resources to serve people affected by pain. • Muscular Retraining for Pain-Free Living. • www.painmed.org/PatientCenter/main.aspx Craig Williamson. Trumpeter 2007. The public information center provided by the American • The Pain Survival Guide: How to Reclaim Your Life. Academy of Pain Medicine includes information for Dennis Turk and Fritz Winter. American Psychological patients on managing pain, including three helpful videos Association 2005. (click the Patient Education link). • www.arthritis.org • Pain Recovery: How to Find Balance and Reduce The Arthritis Foundation is a national nonprofit Suffering from Chronic Pain. Pohl, Szabo, Hunter, and organization that helps people live a better life with arthritis. Shiode. Central Recovery Press 2009. The website contains information on the types • Pain Recovery for Families: How to Find Balance when of arthritis and on managing arthritis pain. Someone Else’s Chronic Pain Becomes Your Problem • www.ninds.nih.gov/disorders/chronic_pain Too. Pohl, Szabo, Hunter, and Shiode. Central Recovery The chronic pain page presented by the National Institute Press 2010. of Neurological Disorders and Stroke includes education and links to clinical trails. • Quiet Your Mind & Get to Sleep: Solutions for Insomnia for Those with Depression, Anxiety, or • www.headaches.org Chronic Pain. Colleen Carney. New Harbinger 2009. The National Headache Foundation provides information and access to resources for people with frequent and extreme headaches. The website includes educational modules, articles, and management tools.

MANAGING CHRONIC PAIN 43

To find resources, go to: intermountainhealthcare.org

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